How to choose a health insurance plan

Find coverage

If you don't have a health plan through your job, you can buy coverage from an insurance company.

Use this website, Texas Health Plan Compare, to find the plan that works best for you.

Other ways to find coverage include:

Buy a health plan during open enrollment

You can buy a health plan during open enrollment. Open enrollment runs from November 1 - December 15.

If you miss open enrollment, you may not be able to enroll until the next one—unless you have a qualifying life event.

Review your medical needs

Take time to review your medical needs. It's hard to know your future healthcare needs. But looking at your past can help you choose a better health plan. Ask yourself:

How often do I see the doctor each year?

If you visit the doctor often, you may want a plan with a higher monthly premium and lower deductible.

Have I needed special medical care this last year? Do I have any medical procedures upcoming next year?

If you will need to see specialists, a PPO plan may be best for you. (See below.)

How much have I spent (out-of-pocket) on care in the last few years?

If you expect to spend a lot on medical costs this year, you may want a plan with a lower out-of-pocket cost and higher monthly premium.

Understand different plan types

These are the plan types you can choose from:

Plan types

Does the plan cover in-network or out-of-network doctors?

Do you need a referral for specialists?

Good option if:

HMO
health maintenance organization

In-network

Yes

You want to pay lower out-of-pocket costs

PPO
preferred provider organization

Both

No

You want a wide range of healthcare provider options both in-network and out-of-network

POS
point-of-service plan

In-network

No

You want to pay lower out-of-pocket costs and choose your own specialists

EPO
exclusive provider organization

In-network

No, if the specialist is in-network

You want to pay lower out-of-pocket costs and you don’t need a lot of provider choices

Search for health plans

The four parts of a health plan to closely look at are:

  1. What the plan covers.
  2. How much you will pay each month (the premium).
  3. The doctors who are in the plan's "network."
  4. What portion of healthcare costs you must pay (for example, the deductible).

Here are more questions to ask yourself when looking at a plan:

  • Can I afford the monthly cost (premium) of this plan?
  • Does this plan cover my healthcare needs? Does it cover any needs we know are coming this next year?
  • Is my primary care provider in this plan's network?
  • If I need to see a specialist or go to the hospital, am I OK with this plan's options?

Compare benefits

On this website, when you compare plans, you can view each plan’s “summary of benefits.” When you read through a summary, make sure you check out:

  • Prescription drug coverage and copays—especially for drugs you're already taking.
  • The plan's "exclusions." Exclusions are services that the health plan doesn't pay for. You can always ask the health plan for their "Disclosures" to learn about their benefits, exclusions, and cost-sharing (how much they pay versus how much you pay).

Note: All health plans in Texas must offer certain benefits—including prescription drugs, emergency services, maternity, mental health, and many more. View the full list of mandated health benefits in Texas.

Compare networks

A plan's network is the group of doctors, hospitals, specialists, and other healthcare providers that are covered. For example, your current primary care provider will be either "in-network" or "out-of-network" for a health plan.

Seeing an in-network doctor usually costs less than seeing an out-of-network doctor.

When reviewing a plan, look at the list of in-network providers—also known as "preferred providers." You can usually find a link to the full list of preferred providers on the first page of a plan's summary on this website.

Check to see if your doctors and providers are included. If they aren't, you may need to pick a different plan or change your doctor to keep costs down.

Compare out-of-pocket costs

Make sure you know what the out-of-pocket costs are for the plans you are looking at:

Deductible

Most plans have a deductible. This is the amount you must pay before the plan pays their part.

Let's say your plan's deductible is $2,500. If you visit the doctor and they charge you $100, you will have to pay $100. If you already paid your deductible of $2,500, you will not have to pay the deductible of $100.

Out-of-pocket limit

Most health plans will limit or "cap" the total amount you must pay out of pocket for the year.

Copays and coinsurance

After you meet your deductible, you will begin paying a copay. A copay is the flat amount you must pay, no matter the type of service. For most plans, you'll have a copay each time you see the doctor after meeting your deductible.

Coinsurance is the percentage of costs you must pay after you've met your deductible but before hitting your out-of-pocket limit. For example, let's say you've met your deductible but you need a surgery that costs $10,000. If your coinsurance is 25%, you would owe $2,500 and your insurer would pay the remaining $7,500.

Premiums and out-of-pocket costs

Usually, the lower your monthly premium (i.e., the amount you pay each month), the higher your out-of-pocket costs will be.

If you are in good health and rarely need to visit a doctor, you might want a plan with higher out-of-pocket costs and a lower monthly premium.

You might want to choose a plan with a lower out-of-pocket cost and higher monthly premium if:

  • You visit the doctor often.
  • You have a chronic disease, such as diabetes, cancer, or heart disease.
  • You're expecting a baby.
  • You take expensive medicines.

Purchase a health plan

Now that you've done your homework, compared plans, and decided what’s right for you, it's time to sign up for your plan. We hope this website made the process easier.

Some people can get a tax credit to help pay for the monthly cost of a plan. To find out if you can get a tax credit, you must: (1) buy your plan on HealthCare.gov, and (2) file a tax return. You will not get the tax credit if you buy the plan through an insurance company. To learn more about tax credits, go to IRS.gov and HealthCare.gov.

To learn more about health insurance in Texas, go to our main TDI website or our Texas Health Options website.